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Study Finds New Biochemical Evidence of E-cigarette Dependence in Youth

March 21, 2023

Editor’s Note: Eli Cahan is a resident physician in pediatrics at University of California, San Francisco and an investigative journalist whose work focuses on the intersection of health equity and social justice. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

In 2016, Surgeon General Vivek Murthy released a report on an issue that, in the preceding decade, had taken the pediatrics community by storm: e-cigarette use. In 2014, e-cigarettes overtook traditional cigarettes as the most commonly used tobacco product among children in the US; between 2011-2015, their use had increased 9-fold. “[I] am emphasizing the importance of protecting our children from a lifetime of nicotine addiction and associated health risks by immediately addressing the epidemic of youth e-cigarette use,” Murthy’s successor, Dr. Jerome Adams, wrote in a 2018 advisory on the issue. He added that the emerging trend was “a cause for great concern.”

The issue persists today. The National Youth Tobacco Survey—an annual questionnaire administered by the Food and Drug Administration in partnership with the CDC to middle and high schoolers—found that over 2.5 million youth used e-cigarettes in 2022.

Even with the prevalence of youth e-cigarette use, companies like JUUL—the market leader, one-third of whose ownership belongs to Phillip Morris, which also owns Marlboro—has historically denied that its e-cigarettes have addictive qualities.

Increasingly, however, evidence points to the contrary. For example, a 2020 study found that 12% of youth who used e-cigarettes in the previous year demonstrated symptoms consistent with tobacco dependence. However, validation of dependence at the molecular level has been lacking.

This week, Pediatrics is early releasing a Research Brief entitled, “Biochemical Validation of Dependence on JUUL and Other E-cigarettes Among Youth“, by John Pierce PhD, Eric Leas PhD, and David Strong PhD from University of California-San Diego that presents evidence to this end (10.1542/peds.2022-059158).

To do so, Pierce and colleagues examined the association between tobacco dependence scores and total nicotine equivalents (TNEs) in urinary samples from nearly 500 adolescents and young adults. The authors found that higher levels of TNEs correlated with higher tobacco dependence scores in those using JUUL, the market leader in e-cigarette products, and other brands of e-cigarettes. Overall, the magnitude of the correlation was equivalent to that seen in traditional cigarette smokers.

Like any associative analysis, this study cannot claim causality. It is possible that participants did not disclose traditional cigarette use, or that other issues of exposure and/or symptom self-reporting convoluted the observed findings.

Nonetheless, this study adds to an important and burgeoning body of literature substantiating the addictive qualities of e-cigarette devices. As such, it reinforces the concern that e-cigarettes are “creating a new generation of Americans who are at risk of nicotine addiction,” as Sylvia Burwell, then-Secretary of the Department of Health and Human Services, wrote in 2016.

Given these warnings, physicians have an important role to play in screening and management of e-cigarette use. Still, such practices are less than routine: a 2022 study found that three-in-ten doctors did not discuss e-cigarettes with their patients.

Pediatricians represent a critical link in this public health chain, both from the standpoint of prevention as well as from harm reduction through weaning and cessation. As the study in this issue of Pediatrics demonstrates, such work is more important now than ever.

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